GHR1000 and IGF1-RX - Fax Order Form

Special Offer: GHR1000 and IGF1-RX™ - Fax Order Form

Please print this form, enter the required information and fax to:

Austin Research Order Processing Department
(410) 374-8087

ORDERING OPTIONS

The following are special pricing options for GHR1000/IGF1-RX™ (please circle one):

Only $125.42 total cost: (1) bottle of GHR1000 + (1) bottle of IGF1-RX™
Only $209.41 total cost: (3) bottles of GHR1000 + (1) bottle of IGF1-RX™
Only $277.45 total cost: (5) bottles of GHR1000 + (1) bottle of IGF1-RX™ (MOST POPULAR)
Only $357.44 total cost: (7) bottles of GHR1000 + (1) bottle of IGF1-RX™
Only $437.43 total cost: (9) bottles of GHR1000 + (1) bottle of IGF1-RX™
Only $517.42 total cost: (12) bottles of GHR1000 + (1) bottle of IGF1-RX™ (OUR BEST VALUE)

      All prices are in U.S. Dollars.  Limit 1 bottle of IGF1-RX™ per order.
      Each bottle of GHR1000 contains a 30 day supply.  Each bottle of IGF1-RX™ contains a 28 day supply.

BILLING INFORMATION

  FULL NAME: ____________________________________________________

  BILLING ADDRESS: ______________________________________________

  CITY, STATE, ZIP: _______________________________________________

  COUNTRY/PROVINCE: ___________________________________________

  TELEPHONE NUMBER: ___________________________________________

  EMAIL ADDRESS: _______________________________________________

  Note: Billing name and address must match the information on your credit card account exactly or it may not be accepted.

SHIPPING INFORMATION

Is your billing address different from your desired shipping address? If so, please enter your billing address above and your shipping address below.

If your billing and shipping address are the same, you may leave this area blank.

  SHIP-TO NAME: _________________________________________________

  SHIPPING ADDRESS: _____________________________________________

  CITY, STATE, ZIP: _______________________________________________

  COUNTRY/PROVINCE: ___________________________________________

CREDIT CARD INFORMATION

  SELECT CARD TYPE:          VISA     MASTERCARD     DISCOVER     AMERICAN EXPRESS

  CREDIT CARD NUMBER: ________________________________________________________

  CARD EXPIRATION DATE: (month/year) ___________________________________________

  CVV2 or CID (3 or 4 digit security code): __________________________________________
   IMPORTANT: THE SECURITY CODE IS A REQUIREMENT. WE MUST HAVE THIS CODE IN ORDER TO PROCESS YOUR ORDER.
   VISA/MC/DISCOVER:  Visa, MC and Discover all use 3 digit codes located on the back of the card, following the credit card number.
   AMERICAN EXPRESS: American Express uses a 4 digit code located on the front of the card, separate from the credit card number.

  ORDER AMOUNT: (6 choices - circle one)                    $125.42   $209.41   $277.45   $357.44   $437.43   $517.42

  TOTAL AMOUNT: (order amount + S&H)                        $ ____________________________________

CUSTOMER AUTHORIZATION

I hereby certify that I am the authorizing card holder of this account. I understand that I will be billed for the total amount calculated above (order amount plus shipping, if applicable). I understand that the name appearing on my credit card billing statement will be either "Austin Research Institute via InternetSecure" or "PAYPAL AUSTINRESEA".

  CARDHOLDER SIGNATURE: ___________________________________________

  This text must be present on order form:

PLEASE FAX THIS COMPLETED FORM TO (410) 374-8087

In most cases, your order will be shipped within 48 hours of receipt of payment.